Extensor pollicis longus rupture after both nonoperatively- and operatively-managed distal radius fractures

Extensor pollicis longus (EPL) tendon ruptures are a rare but recognized complication following distal radius fractures (DRFs) with several proposed mechanisms for their pathophysiology. Existing literature on the incidence of EPL ruptures has largely been limited to small, single-center studies. The purpose of this study was to define the incidence of EPL ruptures following operatively and non-operatively treated DRFs using a large, multicenter database.

A retrospective cohort analysis was performed using the TriNetX database. Patients aged 18 to 90 years who sustained a distal radius fracture between January 1, 2005, and September 1, 2025 were identified using ICD-10 and CPT codes. Patients were stratified into operative and non-operative treatment cohorts. EPL ruptures occurring between two weeks and three years following the index fracture were recorded. Cohorts were matched based on age and demographic characteristics to minimize potential confounding variables. Odds ratios with 95% confidence intervals were calculated, with statistical significance defined as p < 0.05.

A total of 1,206,837 distal radius fractures were analyzed, including 1,093,856 nonoperatively treated fractures and 112,981 operatively treated fractures. In the nonoperative cohort, 1087 EPL ruptures were identified, corresponding to an incidence of 0.1%. In the operative cohort, 411 EPL ruptures were reported, yielding an incidence of 0.36%, nearly three times higher than that observed in nonoperative management. Matched analysis revealed no significant demographic or clinical confounding factors in either cohort.

The incidence of EPL rupture following distal radius fractures were lower than previously reported in smaller clinical series. Operatively treated fractures were associated with a higher incidence of EPL rupture, likely reflecting previously described etiologies, such as hardware-related mechanical irritation, dorsal screw penetration, increased fracture severity, surgical exposure, and disruption of tendon vascularity or gliding mechanics. These findings provide important data for patient counseling regarding treatment risks and underscore the importance of heightened clinical vigilance for early detection of EPL tendon injury following both operative and non-operative DRF management.